Tag Archives: procedure

DENTAL BLOCKS (quick procedure review)

19 Jun

submitted by Amit Kumar, M.D.

Easy procedures providing big-time opioid-free relief!

Can mix 50-50 lido and bupivacaine for quicker onset + longer analgesia combo.

Infraorbital nerve block:Infraorbital 1

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Retract cheek, insert needle next to 2nd premolar, 0.5cm from buccal surface. Advance parallel to tooth

3) You’ll palpate it next to foramen (under palpating finger) at depth of approx 2.5cm

4) Confirm location, aspirate, then inject 2-3 cc local anesthesia

5) Massage tissue for 15 secs to hasten onset

*Intraoral approach provides nearly 2x duration of anesthesia compared to extra-oral approach







Infraalveolar 1Inferior alveolar nerve block:

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Palpate coronoid notch with thumb, and stretch bucally (index & middle finger at angle of mandible outside)

3) Inject 2-3 cc of anesthesia at the site where middle of your thumb nail and pterygomandibular raphe biset

4) Massage tissue for 15 secs to hasten onset

*Will also anesthetize lingual nerve (anterior 2/3 of tongue in that side)

*Anesthetize long buccal nerve of that side, but injecting just distal and buccal to last molar

Reference(s):  Hedges, Jerris R., and James R. Roberts. Roberts and Hedges clinical procedures in emergency medicine. Philadelphia, PA: Elsevier Saunders, 2014. Print.

modified valsalva maneuver (quick reference)

12 Jan

for a more in-depth look, check out last May’s ACEP Now article.

brief highlights:

  • 428 patient study
  • modified valsalva maneuver
    • forced strain (e.g. blow into 10 cc syringe)
    • lie patient flat
    • elevate legs to 45 degrees x 15 seconds
  • return to sinus rhythm at 1 minute:
    • 43% with modified valsalva
    • 17% standard valsalva (strain x 15 sec, no position change)
    • NNT = 4


quick visual aid (start at the 1:17 mark if short on time):


There you go.  Add it to the toolbox.

References: ACEP Now article; video

the “JR knot” for securing central lines

14 Dec

via last month’s Procedural Pause from Dr. James Roberts:

traditionally we’re taught to thread a stitch through the central line base piece as we take the bite.


tie your knot first, then thread through the central line piece and tie it down.

Step 1: suture a knot on your patient

jr suture 1

Step 2: thread it through the central line anchor piece

jr suture 2

Step 3: tie another knot.  it all comes together.

jr suture 3

Simple enough, logical, easy to do.


Add it to the toolbox.


References: procedural pause video


tissue adhesive for fingertip avulsions

3 Aug

nice idea from a recent JEM article:


The Idea:

  • distal fingertip avulsions bleed, hard to dress
  • variable efficacy/availability of bandaging/surgicel/lido+epi/etc
  • gluing it is quick, cosmetic, and even a bit antimicrobial


The Procedure:

  • irrigate well, as usual
  • digital block might help (for irrigation, and ’cause the adhesive will sting a bit)
  • no ointments before or after (will break down the adhesive)
  • tourniquet, direct pressure/milking, elevation — to staunch bleeding
  • apply layer of tissue adhesive
  • let dry, apply another layer
  • let dry, apply another layer


Might consider this trick from a previous post to accelerate drying, especially if you didn’t quite stop the bleeding completely.


Boom, there you go.  


References: JEM article; picture

Humeral IO

28 Jul

back from vacation with some quick procedural tips via a recent EM Resident article:



  • proximal humerus
  • higher flow rates vs. tibia (~ 2x)
  • closer proximity to central circulation


Contraindications (to any IO site):

  • unhealed fracture
  • active soft tissue infection
  • previous IO attempt within 48 hrs
  • inability to find landmarks
  • joint replacement/prosthetic


The Procedure:

  • Positioning (3 possibilities):
    • palm over the umbilicus
    • flexed arm behind back (i.e. palm “under” the umbilicus) — useful during CPR
    • elbow extended, adducted, hyperpronated (i.e. straight arm by side, hyperprone)

  •  Placement:
    • palpate greater tubercle
    • feel surgical neck
    • pick site 1 cm above surgical neck
    • aim 45 degree angle towards contralateral hip

There you go.  Add it to the toolbox.


References: EM Resident article + picture; humerus picture



cool resource: lacerationrepair.com

5 Jun

came across this website, which has a number of handy blog posts and procedure videos on a variety of laceration repair techniques.  Great for the novice learner, with added tips/tricks (subculticulars, nailbed repair, thin skin, etc.) for the experienced practitioner, too.

One highlight that I use quite often: V to Y conversion

Basically, for a big V-shaped lac, the goal is to approximate the corner/apex first, then the rest becomes easy.


  • often needs higher tension, so start it like a horizontal mattress
  • throw a subcuticular around the corner/apex
  • bring it back like finishing up the horizontal mattress.
  • voila!


If you only have 60-seconds: Start at the 0:40 mark.


Just one example, but a good thing to have in the back pocket.

Keep the site in mind as a resource, too. Check it out at your leisure.


References: lacerationrepair.com (+ picture & video).


topical epinephrine for wound hemostasis?

22 May

So your next patient has a good sized avulsion off the pad of his finger that’s still oozing despite his attempts at direct pressure.  

You also can’t find your Surgicel, and your patient hates needles.  You still have the lidocaine with epi in your pocket from when you thought you’d get to stitch something up, though.  Can we use this another way?



soak something (cotton ball/tip, gauze, etc) in epi, then mash it against the thing that’s bleeding



epi (which also comes handily pre-mixed with lidocaine anesthetic in nice dilute doses) is a vasoconstrictor

-> better opportunity for platelets to not get swept away and form clot

dilute concentrations applied topically would seem to have less risk for harm than direct infiltration



quick Pubmed/internet biopsy is interesting, if with limited data:

one big review: 

  • delivery methods included epi + KY, epi-spray, sub-cut infiltration
  • epi achieved hemostasis faster than thrombin, saline, or mineral oil


other random discoveries:

  • lido + epi cotton balls shorted time to hemostasis in rabbit epistaxis
  • epi-soaked gauze reduced mean # of packings, cautery use, and procedure time in kids getting adenoidectomies
  • gauze-soaked epi used for tissue and gallbladder fossa hemostasis during a lap chole
  • suggested for hemostasis in circumcision (just don’t leave it on too long)
  • epi-soaked cotton products for dental procedures (just search the interweb “cotton epinephrine hemostasis”)



mostly studied for ENT uses, but seems to help wound hemostasis

probably worth a shot.  keep it in your toolbox.



References: review articlerabbit epistaxisadenoidectomy; lap chole; circumcision; picture